331 Summary, general discussion and future perspectives Chapter 5 to 8 focused on intraoperative bowel perfusion assessment to reduce the risk of leaks. Another interesting topic, although not covered in this thesis, is the preoperative identification of poor vascularization. Atherosclerotic calcification is one of the main causes of inadequate perfusion 50, 51, which can be assessed on CT scanning. Several studies have shown that the presence of atherosclerotic calcification in the aorta-iliac tract on preoperative CT scans is linked to a heightened risk of AL 52, 53. While calcification in major arteries may reflect anastomotic perfusion, it is essential to note that the primary blood supply to the colorectal region comes from the inferior mesenteric artery (IMA). A retrospective study showed that preoperative mesenteric occlusive disease (70-100% stenosis) of the IMA is associated with a risk of AL in patients undergoing left-sided or rectal cancer surgery 54. Therefore, it might be insightful to further investigate the role of preventive identification of mesenteric occlusive disease in larger trials. If this evidence strength the reduction of leakage rates, a combination of pre-operative and intraoperative perfusion assessment might become clinical practice. PART III: PATIENTS’ PERSPECTIVES ON COLORECTAL ANASTOMOTIC LEAKS While 2-12% of AL patients may die within 90 days after the initial surgery, the majority of these patients survive 55. AL significantly affects postoperative recovery, leading to severe morbidity and often necessitating reoperation. Therefore, it is crucial to understand the impact of this complication as much as possible to improve outcomes. Primarily, comprehending patients’ experiences, preferences, and priorities facilitates the delivery of patient-centered care, wherein treatment strategies are customized to accommodate individual needs and preferences. Such patient-centered, has been demonstrated to enhance treatment adherence, satisfaction, and overall QoL, thereby playing an important role in improving medical outcomes 56, 57. Up to now, there is conflicting evidence available regarding the impact on QoL after colorectal AL, and there is a lack of a clear overview to draw clear conclusions. As patients should be fully informed not only regarding the immediate surgical risks, but also on the impact surgical complications may have on long-term function and QoL, it is crucial to understand this impact. Additionally, to improve QoL outcomes, medical care providers should be aware of the factors that do influence and impact this QoL according to patients. Chapter 9 synthesized available evidence concerning long-term QoL in patients experiencing AL after colorectal resections for oncological reasons. Studies that reported on QoL using validated questionnaires in patients with AL following oncological colorectal resections were included. Thirteen articles, encompassing 4596 individual patients, were summarized in this review, of which 566 patients experienced AL. Significant variability existed among the studies in terms of the questionnaires utilized and the timing of assessments. A total of ten validated QoL questionnaires were used, of which four were used in more than one study; The 14
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